The COVID-19 pandemic and the murders of George Floyd, Ahmaud Arbery, Breonna Taylor, and others have laid bare the harsh reality that U.S. health and social systems are disproportionately harming and killing Black and Brown people. While health professionals readily acknowledge the disparities in morbidity and mortality among communities of color, the full spectrum of social determinants of health remains unaddressed. Policies shaping social determinants of health, including neighborhood segregation and mass incarceration, are imbued with racism and contribute to people of color dying at higher rates.1
Historically, health professionals have used polite, guarded language to talk about societal ills or avoided them altogether. It is time for academic healthcare institutions to raise their voices and take concrete, comprehensive action to dismantle racism and truly embrace diversity, equity, and inclusion at all levels. We, a diverse group of health professions educators and practitioners, offer practical recommendations for galvanizing the much-needed work to address racism within academic institutions. Our recommendations are organized in the following three stages and 10 steps:
Stage A. Preparing the Ground— Identifying Root Causes of Racism
1. Conduct Needs Assessment
Academic institutions committed to anti-racism, diversity, equity, and inclusion should start with a rigorous needs assessment to uncover and understand their current situation. The Multicultural Organization Development Stage Model2 suggests that racism and multiculturalism should be viewed as a spectrum rather than a binary model. Explicit institutional values—such as mission statements and policies—and implicit messages expressed through everyday practice, cultural norms, and products or services (e.g., curricula and healthcare services) must be analyzed. This should be a data-driven process that engages the perspectives of all stakeholders, particularly Underrepresented Minority (URM) students, faculty and staff, through questionnaires and focus groups, in addition to auditing the entire organization by reviewing personnel files (e.g., for hiring and firing patterns), admission and graduation rates, filed grievances, and budget allocations. Data should be viewed through the lens of demographics with an eye for identifying inequities. While a committee of change is helpful for collecting, organizing and reporting such data, ultimately the review and analysis should be done within each department, so that all groups can participate in identifying gaps and next steps.2 A thoughtful needs assessment will be the cornerstone of all subsequent steps.
2. Refine Mission Statement
A carefully crafted mission statement allows institutions to reflect on the degree to which actions and policies align with values of anti-racism, diversity, equity, and inclusion. Institutions should consider engaging a community advisory committee to ensure that the mission statement reflects the needs of the communities it serves.
3. Redistribute Power
Leadership in medicine tends to be more homogeneous than the workforce as a whole, concentrating decision making among predominantly white voices. Examine whether the people impacted by institutional policies and processes have a voice. By deliberately sharing power with faculty of color, students, and the community, institutions will be better able to identify biases that perpetuate institutionalized racism and implement changes towards a more inclusive organization. This step is integral to admissions and recruitment, curriculum development, learning environment, promotions criteria, research priorities, as well as community outreach and pipeline programs.
Stage B. Sowing the Seeds—Dismantling Institutional Racism
4. Build the Pipeline
It is critical to support the development of future healthcare professionals from the communities served by institutions. Since diversity in medical schools is lacking, support and mentorship programs should begin early. This should include partnering with public schools and after-school programs to foster a pipeline of diverse students choosing to pursue medical careers.
5. Revamp Hiring and Admissions
Develop hiring and admission goals and policies to better reflect the patient population served by the institution. This requires an anti-bias lens in all process steps: review of applications, selection of interview candidates, interactions during interviews, and candidate ranking. Truglio, et al,3 outline a strategy that includes community input for the hiring mission, academic metrics designed to eliminate structural racism, steps to reduce implicit bias in the interview process, and a ranking committee broadened to modify current power structures.
6. Realign Academic Environment
Academic institutions must support the recruitment, retention, and mentorship of more URM voices into the power structure of academic medicine. This includes dedicating time, resources, and funding to support mentorship of URM faculty, and recognizing a broader range of promotions criteria, recognizing diversity work, mentorship of learners and junior colleagues, and committee work. Compensate and protect faculty time for diversity initiatives.4
7. Refine Curriculum
Health educators should ensure that curricula teach race as a social construct, not a biological difference, and highlight the structural nature of heath inequities. In addition, medical and health professions curricula contain numerous examples of lectures, problem-based learning cases, and clinical vignettes that reinforce stereotypes, implicit bias, and prejudices. Educators should review their curricula for bias according to available anti-bias checklists, then make necessary corrections.5 Curriculum committees can incorporate such checklists into course reviews and invite community members to participate in curriculum development.
8. Appoint and Empower Chief Diversity Officer
A Chief Diversity Officer (CDO) is a critical resource for institutional guidance, creating systems of accountability, coordinating leadership efforts between departments and schools, and implementing plans to create a culture of anti-racism, diversity, equity, and inclusion throughout the institution. The CDOs must be sufficiently empowered by a President, Provost, and Deans who inherently believe in the value of diversity.
Stage C. Tending and Sustaining the Crop—Dismantling Personal Racism
9. Provide Implicit Bias and Allyship Training
Institutional cultural change requires operationalizing a framework that dismantles individual presumptions, prejudices, discrimination, and racism, and builds an authentic culture of allyship. All individuals working within healthcare environments need training to recognize and address explicit racial discrimination and micro-aggressions that may emanate from or towards patients, trainees, faculty, staff, and other personnel. Furthermore, it is vital to recognize that individuals within academic institutions may be anywhere on the spectrum from denying racism, to learning and actively engaging in anti-racist practices. Creating a culture of trust and humility starts with acknowledging that all of us possess some degree of implicit bias. This needs to be coupled with the willingness to open our hearts and minds to allow for challenging conversations and mutual learning through sharing of missteps and struggles.
10. Develop Policies and Procedures to Report and Respond to Bias and Racism
Complementary to building safe spaces and training to recognize and speak up against micro-aggressions and racism, establish an anonymous reporting system. This system can provide ongoing accountability, rapid corrective action, and continuous quality improvement through regular program evaluation. This effort should include teaching sessions that may promote bias, stereotype or shame, or micro aggressions in the classroom or in the clinical setting. Transparency and psychological safety are paramount for any reporting system: knowing that raised concerns are deliberated through a fair process and how these are ultimately addressed (safeguarding privacy and ensuring whistle blower protections) are essential. By dismantling personal racism, we can build a culture that promotes courage for recognizing, speaking, and standing up to counter racism.Conclusions
Academic healthcare institutions must act to dismantle personal and institutional racism that stem from centuries of lack of knowledge, implicit bias, and intolerance. We propose a step-wise process to systematically address the institutional culture, equitable redistribution of power through hiring and promotions, community-engaged approach to build a workforce reflective of its diversity, refinement of the curriculum and learning climate, education and training to build the next generation of anti-racist health workforce, and establish a system of accountability. The path forward may be fraught with challenges, including educating and engaging those who may be unwilling to participate in this type of transformative change. Despite the hurdles that may lie ahead, the stakes are too high to maintain the status quo.
Corresponding author: Memoona Hasnain, MD, MHPE, PhD (firstname.lastname@example.org)
Authors’ Note and Acknowledgement: The authors are members of the Community of Practice, National Collaborative for Education to Address Social Determinants of Health (NCEAS), supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS), grant number UH1HP29963, Academic Units for Primary Care Training and Enhancement.
Disclaimer: The views expressed in this article are solely the opinions of the authors and do not necessarily reflect the official policies of HRSA, HHS, or the U.S. government.